Transitional Care RN collaborates with the client, social work case manager, and other healthcare providers to facilitate client access to those health and social services which enhance the client's health and well-being and his/her ability to adhere to the prescribed medical treatment regimen in the most efficient and cost effective manner possible. Transitional Care RN provides services to the client in a variety of community and clinical settings. Works with the multidisciplinary team to identify patients at increased risk for readmission and provide care coordination services throughout the care continuum and into the outpatient setting by working with the Population Health and Case management teams as well as other community partners and resources. Works in conjunction with the Population Health team to expand outpatient services and to support its mission of reducing readmissions through improving transitions of care.

4. Acts as a client advocate for the development of community resources and functions as a liaison to external agencies relaying information to others which may impact care and/or services to clients.

5. Collaborates with regional hospitals and identifies vulnerable high risk ED and inpatients. Educates hospital team members and patients about available Network services.

6. Provides at least one home visit within 24-72 hours of discharge focusing on medication reconciliation, patient specific disease education and preparation for follow-up appointments with provider. Patients followed telephonically for up to 90 days post discharge.

Qualifications

Bachelors degree in nursing

Current MD RN licensure

3-5 years of experience in an acute care setting preferred experience with

Strong assessment skills

Ability to prioritize multiple tasks

Ability to interact with various members of the health care team

Ability to advocate for the patient/family

Must be licensed and able to operate a motor vehicle as well as maintain automobile insurance and abide by requirements listed in AHC's Automobile/Fleet Management policy

Evidence of at least one year of previous experience as a nurse case manager or discharge planner in the acute care setting desirable

Evidence of a high level of skill in assessment, identification of problems, care planning, identification and development of community resources and patient/family teaching required.

Ability to work effectively with others to accomplish organizational goals and to identify and resolve problems.

Work Schedule

This is a full time day position. You will regular business hours Monday-Friday.

Tobacco Statement

Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, We will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine use.

We will withdraw offers of employment to applicants who test positive for Cotinine (nicotine). Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing.

Equal Employment Opportunity

We are an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.